Saturday, February 11, 2012


I am seeing the world of medicine change before my eyes, and I wonder where we’re going.

Never before has there been more information at our disposal, yet more confusion. Like molecules being heated, the Brownian motion happening in medicine seems completely ineffectual for those of us on the front lines of care, geared more toward expensive facades than substance.

For the most part, doctors keep their heads down. Most of us are busy caring for patients, pushing to get home at least once each week before dinner. Most are humble servants to their patients, working tirelessly for their benefit. Sure, there are a few doctors participating in policy or medical associations, but it's clear to the rank and file that their leadership has already cashed out from patient care and are no longer participants in what medicine has become today. Worse: they’re too few in number and too underfunded and occassionally displayed as hood ornaments to validate a central policy decision.

Then there's call. No one likes call, but it must be covered. Doctors understand that medicine is 24/7/365 affair. But there's more people now, more places, and yes, more call. The burden falls on the doctors, so the tremors resonate louder. No large ones, mind you. But they're happening. Doctors are pleasantly, professionally, reaching critical mass.

I suppose there have always been rumblings in medicine, but somehow, the rumblings seem louder than usual. The promises of more with less is taking it’s toll. There are fewer perks these days for the work and risks involved for doctors. No one seems concerned, really, about liability reform. No one cares about doctor pay, except that it’s too much. Even the physician cheerleaders for the current reform efforts look tired. It’s hard to alter the course of a ship guided by business interests steeped in tradition, I guess.

This week doctors saw residents recalled to fill staffing shortages in a large, new teaching facility across town. Doctors there, it seems, were an afterthought. Residency work-hour restrictions prevent the remaining residents from filling the void left by their colleagues. So the extra workload necessarily falls on those who are ultimately responsible and already at risk for untoward outcomes: the already-busy attending physicians. Residents see it in their exhausted attending's eyes. Nothing is said, but the undercurrent is palpable. You see starry-eyed hospital administrators hell-bent on growth don’t fill those voids, doctors do.

Add to this, doctors read how another insurer has decided to change how they will pay doctors. At least that's how the headline read. But insurers don't pay doctors anymore, they pay their employers. How doctors are paid no longer relies on fee for service - that was gone long ago. But the public is told that the fee-for-service is what is broken. But doctors know what's broken are the incentives to maintain the middlemen that course through every layer of health care delivery that exists today in medicine. And God forbid there be more than a cursory mention of defensive medicine's toll. So the cash cow continues: policy-makers have decided that checking boxes on a computer screen or magically limiting readmissions is how "doctors" are to be paid. As if doctors can look in a crystal ball or should be expected plan for every contingency or every personal decision a patient might make or forget to make. Clearly these policy wonks ever heard of the People of Walmart. You see, for them, it's all about what they perceive is quality, remember, and quality involves a computer these days, not to mention maintaining shareholder value. So while insurers continue to cut payments to doctors and you can't get an appointment, remember: that's "quality" working for you.

Oh, and did I mention there’s a hiring freeze right now?

More tremors.

Can you feel them?



Anonymous said...

Go Wes!

I am surprised that you still have time to blog. Isn't the DOJ waiting for your deposition on that ICD in the patient who had the troponin bump after being shocked 10 times?

The apparatchiks are getting rich, though. Check out the $20B printed for the CMS center for 'government innovation'. Oxymoron?

Is anyone else insulted by the verbiage 'aligning incentives'? I'm not tryng to care for my patients as much as I am ripping off the government?! So, if the government pays me to keep my patients healthy, I will do the right thing. Basically, when it comes to lining their own pockets, we can't trust doctors but somehow we can trust them to save our lives when we are having an AMI. What inflammatory garbarge tolerated by physicians. As a whole, we are the worst self immolators. Does anyone believe that 'aligning incentives' will empty out the ICUs full of 80-90 y.o. on the vent with an IABP? The tsunami of elderly is overwhelming the system and costs will continue to escalate. Our physician leaders offer us up as the sacrificial lambs in the name of 'bending the cost curve'.

Instead of the politicians stepping up and telling the truth about limitations of care that will/must be imposed, our physician leaders support ACOs (capitation revisited). ACOs will give the politicians cover to avoid telling the truth that Medicare overpromised. The docs will be the ultimate henchmen when the administrators describe our new payment initiatives where our paycheck will depend upon rationing. That's right. Just say no...if you want to get paid. Sorry, you put in too many ICDs and you just lost your bonus. Despicable. This is where we are being lead. We may be abused by many but our patients still love and trust us. Soon, that too will be gone when incentives are 'aligned'.

MooreFish? said...

Ride on Bro-

It is time for a "Physician- Spring".

With social media a powerful statement could be made, but before it happens we should decide on what we want and how to proceed!



Keith said...

Health care cannot continue the status quo. To do so will bankrupt our country and strangle our competitiveness as a nation.

Our helath care system has been built on the wrong incentives. Instead of dealing with the underlying causes of hypertension, diabetes, elevated cholesterol, etc. etc., we have become a reactive system that treats the end result of these conditions at ennormous cost. Threats to the flow of dollars from our state and federal coffers to support these high cost treatments will, with out doubt, be met by stiff resistance by those that benefit the most from the status puo. But inaction is not an alternative. While many complain, no one offers an acceptable alternative to controlling spiraling health care costs, most of which go to futile end of life care and heroic interventions that often do not sustain quality years of life.

Many countries continue to provide quality health care for their citizens at much less than we do in the good old US of A; these are often dismissed as socialist systems that restrict health care through rationing or denial of treatmen., But these systems seem to distribute health care resources in a more sane and sensible way, treating those most in need appropriatly and not wating resouces on futile interventions. Instead of this appraoch, we choose to limit care for our citizens on the basis of ability to pay, and deny or limit treatment for many chronic conditions till the individual suffers the catastrophic complications of this neglect. Then we jump in with very expensive inerventions to correct for this neglect. Is this how anyone would structure their health care system if our objective was to keep people healthy by the least costly method?

Does anyone truly believe that our system does not incentivse the use of expensive and profitable tecnology and that there are innumerable examples of how physicians and our health care system has promulgated this overuse of resources? Whether it be imaging technology, ICD and stent placement, back surgery, etc, etc., we see that we lead the world in the frequency with which we use our technology.

The future is scary, but the status quo is even scarier.

Anonymous said...

"Does anyone truly believe that our system does not incentivse the use of expensive and profitable tecnology and that there are innumerable examples of how physicians and our health care system has promulgated this overuse of resources?"

An avarice filled cardiologist is reimbursed an excessive $200 for a LHC. This perverse incentive has 'promulgated overuse of resources'. You can have your $200 and all the radiation, call, nights, weekends, holidays, threats of lawsuits.

Just wait until your doctor (who you can't trust anyways) is incentivized to deny your healthcare. Search for 'Kaiser Permenente abuses' and see the result.

Anonymous said...

I'm glad someone brought Kaiser into this. We are the only PHYSICIANS trying to provide high quality care AND control costs.

Sure, I deny them their every 6 month stress test... don't believe every rant you read on the web.

Anonymous said...

Someone rename Kaiser the Borg. "Resistance is futile. You will be assimilated."

Has anyone ever noticed that there is no dissent at Kaiser? If you dissent, you are asked to leave. Kaiser attracts docs who are trained to say NO.

Remember the GUSTO I trial where there was an absolute difference of 1% between streptokinase and a-tPA. Based on that 1% difference, streptokinase was relagated to the waste bin.

Kaiser thrives on that 1% difference. The theory is you can send 99% home with no testing and only 1% will be harmed. Most of the time, you can get away with it. It has taken a while but that 1% is building internet sites and fighting in other ways.

Kaiser is doomed and all the physicians who previously worked there will have tarnished reputations.

Good Luck KP.

Anonymous said...

I'm sorry to hear ignorant comments like that about KP.

Actually, the interesting thing about KP is that at KP i can't turn away ANY patients. In private practice I probably turned away 1% for a variety of reasons, but KP patients have "pre-paid" so we have to treat and find solutions to even the most difficult patients.

I'm not saying every patient (or MD) is happy within KP, but what private practice group is actively looking at illness and trying to find options that are both therapeutic and cost effective?

And how about all the over-treating that goes on in the US? All the unnecessary procedures, tests, etc. I like to tell my patients that I make the same amount of money if I spent 4 hours in the operating room or sit in my office and drink coffee... so if I say they need a surgery, they can be comfortable that I'm not secretly thinking about my BMW payments.

Keith said...

KP is a workable model of what a non fee for service health care organization looks like. It is a threat to all those who have obtained sub specialty training in the predominantly procedure oriented fields, who see possible limitations on the use of their skills, and quite possibly threats to their income. It is understandable to see individuals lashing out at this threat. What we need to be looking at these examples such as KP and whether they offer bettter value for the cost vs. traditional fee for service. Those threatened by this model need to consider if they might be better off working in a system where the reimbursement is not driven by how many patients you see or procedures you do, but by whether the health and well being of the patient is enhanced. I think we will all find better job satisfaction potentially in such a system.